Veteran Suicide and the Family

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Feb 20, 2024

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VETERAN SUICIDE AND THE FAMILY 1 A Review of the Literature Veteran Suicide and the Family Tiffany Shotwell Department of Psychology, Capella University Psy8002 – Foundations of Theory and Practice for Doctoral Psychology Learners Dr. Karen Heller 12/3/2023

VETERAN SUICIDE AND THE FAMILY 2 Abstract Veteran suicide is a critical and harshly visible issue in the United States (Morral et al., 2023). Some examinations of this tragic anomaly have suggested that veterans and enlisted personnel were more prone to suicidal ideation and intent due to extreme mental and personal sacrifices through having waived constitutional rights, endured repeated physical stress, and the direct and sudden loss of personal citizenship (McCullers, 2023). A comparison of suicide rates for military veterans versus first responders, Law enforcement, and civilians suggested the increased risk for veterans had less connection to deployment than previously understood (Sonza, 2018). A critical deficiency of the existing research was that most studies conducted have been focused on governmental adaptations, rather than the veteran’s community. Meanwhile, the most significant portion of existing studies focused only on clinical relationships, rather than social bonds wherein veterans had already established trust (Dubois et al., 2023). This literature review will discuss the current research on veteran suicide, agency response, current prevention strategies, and how these components interact in an attempt to prevent unnecessary death. This literature review will also discuss suggestions for interventions, resources to help better predict and identify suicidality, and recommendations for future research.

VETERAN SUICIDE AND THE FAMILY 3 Introduction Research has demonstrated that the rate of veteran suicide death was at least 1.5 times greater than that of non-veteran counterparts in the United States, after adjusting for age and gender variances (Morral et al., 2023). The premise for one recent study was that veteran risk was elevated relative to nonveterans (Morral et al., 2023). The direct result of the Morral inquiry showed nearly 6 times greater elevation in risk than non-veteran counterparts (Morral et al., 2023). This demonstrated that even where suicidal thoughts were not acted on, the risk was not being properly mitigated by systems in place (Morral et al., 2023). While many studies were conducted to evaluate veterans and their risk for suicide, very little research exists regarding the impact of family interventions concerning veteran suicide (Dubois et al., 2023). The Dubois study examined the variable characteristics among family members to determine which dynamics produced a protective factor against suicide, as opposed to those dynamics that directly created further risk factors for the veteran (Dubois et al., 2023). Further research could be conducted regarding family psychoeducational interventions for veteran suicide. Studies can be conducted to apply previous findings concerning risk factors to the creation of psychoeducational skills groups aimed at families. The research can be expanded on how to create intentional protective factors against veteran suicide, where previously few had existed. Literature Review Quantitative Evidence of The Issue The psychological well-being of military veterans in the United States remains a critical topic in public health research and advocacy (Mcullers, 2023). It was determined that as many as

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VETERAN SUICIDE AND THE FAMILY 4 22 veterans per day committed suicide in the United States (Morral et al., 2023). Conversely, an average of one active duty servicemember per day committed suicide (Morral et al, 2023). Yet another study demonstrated that quantitatively, a person was more at risk as a person for suicide while in their own home with military veteran status than a person who was engaged in active military assignment (Blosnich et al., 2020). Studies were also conducted to analyze the difference in risk for suicidality among veterans versus law enforcement, first responders, and civilians (Sonza, 2018). This comparison of suicide rates for military veterans versus first responders, Law enforcement, and civilians demonstrated a higher risk for veterans than others, such as first responders, who had been exposed to similar levels of occupational trauma (Sonza, 2018). The findings suggested the increased risk for veteran suicidality had less connection to deployment than previously understood (Sonza, 2018). Causation As veteran suicidality became a critical issue in the United States, several studies were conducted to understand the social determining factors that led to suicidal behavior in former military service personnel (Blosnich et al, 2020). The Blosnich study, for example, was aimed at which social determinants of health impacted veteran suicidality scores (2020). These factors were exposure to violence, housing instability, financial difficulties, legal complications, social deficits, lack of access to care and reliable transportation, and other psychosocial needs (Blosnich et al., 2020). The study showed that those with measurable deficits in social determinants of health (SDH) were at significantly higher risk for suicidality than those with no significant unmet social needs (Blosnich et al., 2020).

VETERAN SUICIDE AND THE FAMILY 5 A quantitative study in 2020 proposed that military veterans who held minority status related to sexual orientation and identity were also at significantly higher risk for suicidal behavior and ideation (Lynch et al., 2020), further supporting the idea that deficits in the veteran’s social circle increased the risk of suicidality. The study suggested that a veteran who identified as part of the LGBTQIA+ community presented a higher risk for suicide both during and after military service (Lynch et al., 2020). Expanding the knowledge base on causal factors leading to veteran suicide, a longitudinal study examined risk factors and causation for suicidal ideation (Schafer et al., 2022). The study demonstrated that in addition to social factors affecting the veteran suicide risk, anger, aggression, substance use, insomnia, and traumatic brain injury were also statistically significant risk factors (Schafer et al., 2022). One study concerning the impact of military service proposed that even in the absence of battlefield trauma, enlistment in the Armed Services had a direct impact on the individual psyche (Mcullers, 2023). The study identified psychological stressors and sacrifices that occur from the moment an enlisted member signs their contract. This included but was not limited to military personnel being required to sign away their constitutional rights to personal citizenship as a condition of service (Mcullers, 2023). Response The magnitude of the issue at hand makes veteran suicide a topic of perpetual examination. While studies were conducted to examine causation, some advancements have been made toward implementing interventions for suicide prevention (Knapp, 2023). An article in 2022 proposed that creating effective safety plans was paramount to the prevention of veteran suicide (Knapp, 2023). It was suggested that if veterans had safety plans in place, they would be less likely to act on suicidal ideation when struggling (Knapp, 2023). A 2017 examination

VETERAN SUICIDE AND THE FAMILY 6 proposed that the Veterans Health Administration (VHA) needed to adapt its model for suicide prediction to effectively reduce veteran suicide (Kessler et al., 2017). Based on the results of this 2017 research, the VHA adopted a program using the elastic net model used in the study to begin targeting veteran patients who were at the highest risk for increased suicidality and worked to provide preventative interventions (Kessler et al., 2017). Additionally, in response to the increase in veteran suicide, the VHA implemented a standardized, three-stage suicide risk screening intended to predict and reduce veteran suicide (Nwangwu et al., 2021). Despite organizational efforts to predict veteran suicide, numbers have continued to rise over the last decade (Nwangwu et al., 2021). It was believed that for an intervention for suicide prevention to be effective, there must be a relationship of trust between the veteran and the intervening individual (Dubois et al., 2023). Assuming this premise is true, interventions provided solely by organizational staff may not be as well received as those that utilized family as agents for safety (Dubois et al., 2023). Conclusion Military veteran risk for suicidality is a topic that has been scrutinized for years due to the consistent rise in the number of incidents over the last decade (Nwangwu et al., 2021). Research has begun examining what factors contribute to veteran suicidality and how it can be prevented (Kessler, 2017). After military service, it is critically important that veterans have access to strong social support (Blosnich et al., 2020). Additionally, it is important to ensure that the veteran does not have any deficits in their hierarchy of needs for survival such as housing, safety, sense of belonging, food, and clothing (Dubois et al., 2023). After military service, veterans are more susceptible to suicidal ideation and behaviors (Mcullers, 2023). In addition to the lack of appropriate social support following service, data suggested that regardless of overseas

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VETERAN SUICIDE AND THE FAMILY 7 deployment or level of combat exposure, military personnel, and veterans were more at risk for suicide in large part due to the personal sacrifices necessary to participate in military service. Research needs to further expand by including studies that focus more specifically on families as the source of intervention. While psychoeducation should and will always be provided to VHA staff and military medical personnel, the family and loved ones have proven to be a significant influential factor in a veteran's level of suicidal ideation and behaviors (Lynch et al, 2020). Providing psychoeducation to families could allow for further prediction and prevention of veteran suicide, especially if provided with information on aspects such as determinants of health and risk factors for suicide. Such studies should include examinations of family dynamics and stress related to supporting a suicidal person. Large group interventions aimed at providing lethal means conversations should be examined to determine both feasibility and efficacy. There are limitations in the current research concerning veteran suicide and the solution to reducing risk. Although much has been done to understand the causal factors of veteran suicide, nearly all of the proposed interventions have been focused on the VHA as an organization, or the individual veteran. When the individual veteran is used as the meter, standardized evaluations are being used that may leave gaps in properly identifying risk (Nwangwu et al., 2021). It has been concluded empirically that veterans are at significantly higher risk for suicide than their non-military counterparts (Morral et al, 2023). Studies have been conducted ad nauseam to determine causation, but significant gaps exist in the knowledge of the solution, especially when considering providing structured psychoeducation to family members to better predict and prevent veteran suicide. Not enough research exists on lacing the knowledge with those who spend the most time with at-risk veterans.

VETERAN SUICIDE AND THE FAMILY 8 References Blosnich, J. R., Montgomery, A. E., Dichter, M. E., Gordon, A. J., Kavalieratos, D., Taylor, L., Ketterer, B., & Bossarte, R. M. (2020). Social determinants and military veterans’ suicide ideation and attempt: A cross-sectional analysis of electronic health record data. Journal of General Internal Medicine: JGIM, 35(6), 1759-1767. https://doi.org/10.1007/s11606- 019-05447-z DuBois, D., Richmond, R., Stephanie Roberts, L., Mahar, A., Fear, N., Gill, K., Samantha Leroux, J., & Cramm, H. (2023). A scoping review of military and veteran families within international suicidality and suicide prevention research. Preventive Medicine Reports, 33, 102206-102206. https://doi.org/10.1016/j.pmedr.2023.102206 Kessler, R. C., Hwang, I., Hoffmire, C. A., McCarthy, J. F., Petukhova, M. V., Rosellini, A. J., Sampson, N. A., Schneider, A. L., Bradley, P. A., Katz, I. R., Thompson, C., & Bossarte, R. M. (2017). Developing a practical suicide risk prediction model for targeting high-risk patients in the Veterans Health Administration. International Journal of Methods in Psychiatric Research, 26(3), e1575. https://doi.org/10.1002/mpr.1575 Knapp, S. (2023). The essentials of creating effective safety planning-type interventions for suicidal patients. Practice Innovations , 8(2), 131–140. https://doi-org.library.capella.edu Lynch, K. E., Gatsby, E., Viernes, B., Schliep, K. C., Whitcomb, B. W., Alba, P. R., DuVall, S. L., & Blosnich, J. R. (2020). Evaluation of suicide mortality among sexual minority US veterans from 2000 to 2017. JAMA Network Open , 3(12), e2031357-e2031357. https://doi.org/10.1001/jamanetworkopen.2020.31357

VETERAN SUICIDE AND THE FAMILY 9 McCullers, A., B.S. (2023). The Peace Exchange: Physical and psychological sacrifices of military personnel from historically marginalized backgrounds. American Journal of Public Health , 113(2), 149-151. Morral, A. R., Schell, T. L., & Smart, R. (2023). Comparison of suicide rates among US veteran and nonveteran populations. JAMA Network Open , 6(7), e2324191-e2324191. https://doi.org/10.1001/jamanetworkopen.2023.24191 Nwangwu, H. , de Peralta, S. , Birman, S. & Hicks, R. (2021). Implementation of the standardized, evidence-based three-stage suicide risk screening: Experience of a large Veterans Affairs medical center. Journal of the American Association of Nurse Practitioners , 33 (10), 838-846. Doi: 10.1097/JXX.0000000000000540. Schafer, K. M., Duffy, M., Kennedy, G., Stentz, L., Leon, J., Herrerias, G., Fulcher, S., & Joiner, T. E. (2022). Suicidal ideation, suicide attempts, and suicide death among veterans and service members: A comprehensive meta-analysis of risk factors. Military Psychology , 34(2), 129-146. https://doi.org/10.1080/08995605.2021.1976544 Sonza, S. (2018). A comparison of suicide rates amongst the military, veterans, law enforcement, and the civilian population (Order No. 10684633). Available from Psychology Database . (1991489016). https://www.proquest.com

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